How Solid Is The Primary Care Foundation Of The Medical Home?

The patient-centered medical home (PCMH) has received attention as an improved care delivery model for primary care physicians — and possibly also for specialists who serve as principle physicians for patients with particular chronic conditions. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) identified the PCMH model as a presumptively qualifying Alternative Payment Model (APM) that would give physicians higher payments. And a recent summary of the latest evidence found reason for optimism about the potential impact of the PCMH model, not only on quality but also physician morale — raising the hope that the proliferation of the PCMH model might attract more physicians to careers in primary care.

At the same time, more robust studies that have used difference-in-differences analyses—controlling for the likelihood that practices that become PCMHs might be higher performers to start with—had less impressive results, especially regarding health care spending. The evidence summary emphasizes that PCMHs differ in their implementation and performance, and calls for more research to identify which components of the PCMH have the greatest impact.

But there’s a more fundamental issue to consider regarding which aspects of primary care practice make the difference in performance. Many of the versions of the PCMH—and the accompanying recognition instruments that assess practice adoption of the PCMH model—do not assure that the well-established four “pillars” of primary care are robustly adopted by PCMH practices. Rather, it’s simply assumed, despite growing evidence to the contrary, that practices are meeting the “four C’s,” as described by the late Barbara Starfield — providing first contact, continuity, comprehensiveness, and coordination.

We would suggest the current emphasis of PCMH demonstrations and models on the fourth C, care coordination, is partly a reaction to decline in primary care commitments to the three other C’s, contact, continuity, and comprehensiveness — decline that seems to have been simply accepted as facts of life by most PCMH architects. It’s no wonder the PCMH emphasizes care coordination — much of the care received by primary care clinicians’ patients is now being performed by others, without their involvement.

With funding from the Commonwealth Fund, we recently completed a study examining the interaction of advanced primary care practices and accountable care organizations (ACOs). Our approach involved 32 interviews with individuals in primary care practices or leadership roles in ACOs and insurance companies. Here we present information that was not a formal part of the study that will be published.

We asked physicians about the extent to which PCMHs and/or ACOs recognize the importance of the four C’s, and for examples of practical approaches for assuring the presence of these elements of primary care practice as PCMH transformation proceeds. This blog derives from our review of the literature on PCMHs, buttressed by respondents’ comments.

Evidence Of Worsening Primary Care Performance On Three Of The Four C’s

First Contact

Two Commonwealth Fund international surveys found the U.S. at the bottom on “after-hours” care. Only 29 percent of U.S. physicians said their practice had arrangements to ensure after-hours contact or care for patients other than automated phone referral to emergency rooms. And only 30 percent of patients said it was very or somewhat easy to get care on nights or weekends. This sorry performance exists despite evidence that ready access to one’s primary care physician after business hours is associated with improved patient outcomes and lower emergency room (ER) use.

PCMH expectations typically do include after-hours phone availability and a system for seeing urgent patients during office hours, but not much more. In particular, there is no expectation that PCMH clinicians will actively engage with ER physicians in clinical decision making and the patient’s “disposition” (an unfortunate term used to describe whether a patient will be admitted as an inpatient, observed for a while, or referred back to their community physician for needed follow up).

In our interviews with primary care and ACO physicians, we heard that the traditional conversations between the responsible ER physician and the patient’s regular or covering clinician to discuss disposition rarely take place any more, often resulting in avoidable admissions.

Continuity

A central expectation associated with continuity is that the primary care physician (and the extended care team) would be a major source of support for patients experiencing health crises and would be an important contributor to decision making for patients because of their familiarity with their patients’ values and preferences. That expectation does not require that physicians be the attending physician of record during a hospital stay, but rather that they participate as needed as a member of the virtual inpatient team — sometimes serving as the patient’s advocate in the growing bureaucratic environment of hospital care today.

Yet, for various reasons, hospitalists and specialists have supplanted the primary care physician — many of whom no longer have anything to do with their hospitalized patients. This, despite evidence that greater continuity—in, during, and out of the hospital—leads to improved patient outcomes. Further, it seems that care provided by hospitalists without active participation by the patient’s regular physician does not improve long-term costs and outcomes. Yet, PCMH assessments generally place no expectations on the primary care physician to participate in hospital care.

Comprehensiveness

A recent review of the literature on comprehensiveness finds a dramatic decline in the extent to which primary care clinicians recognize and meet the majority of their patients’ physical and mental health care needs. This includes prevention and wellness, care for acute and chronic conditions, and comorbid condition management. Yet, we know comprehensiveness is linked to lower health care spending. The deterioration in this aspect of primary care is demonstrated by the fact that between 1999 and 2009, physician referrals (not just from primary care) increased from 41 million to 105 million per year, a 159 percent increase in only a decade.

While many PCMH advocates reasonably emphasize the benefits of a multi-disciplinary care team that advances comprehensiveness (e.g., through care coordinators, health educators, nutritionists, part-time pharmacists), most PCMH assessment tools completely ignore the role of the physicians themselves in providing comprehensive care. Again, there seems to be an implicit assumption that the medical home needs to emphasize coordination in order to make up for the reality that patients inevitably will be getting a lot of their care all over town. The decline in primary care comprehensiveness is simply accepted.

Despite this expert advice, PCMH recognition standards include few expectations that practices in fact adhere to the fundamental tenets of primary care. We suggest that may be why PCMH initiatives typically struggle to generate savings, despite well-intentioned efforts.

We acknowledge that the decline in attention to contact, continuity, and comprehensiveness likely reflects the reality of the “hamster on a treadmill” state of primary care. Asking physicians to take patient or ER calls at 2:00 AM, to interrupt a packed office schedule to make rounds on an inpatient, or to avoid referring when that seems the easiest course to take on a busy day may seem overly ambitious, especially as long as fee-for-service remains the predominant payment approach. Understandably, physicians increasingly value their lifestyle and seek more predictable work hours, so night-call and inconvenient visits to hospitals and nursing homes are not high on their list of things to do — even though that is where their value might best be advanced.

Addressing First Contact Care

In our interviews, we explored the importance of assured, after-hours access to a patient’s practice and continuity into and out of inpatient hospitalization, exploring the extent to which PCMH and ACO priorities address these core elements of traditional, high-quality primary care.

There was general agreement that an ACO was in a position to use its clout to improve often non-collaborative hospital-ambulatory practice communication. At the same time, the interviewees often thought it a primary care physician’s obligation to provide after-hours service, whether or not they were part of an ACO.

Although some PCMH initiatives encourage their practices to offer after-hours availability, such as staying open a few weeknights and perhaps Saturday morning, some respondents emphasized the crucial role of phone contact with patients at all hours. This involves not only direct contact with patients but also with ER staff as part of their evaluation of the patient and, when important, to participate in decision making regarding disposition.

Respondents emphasized that patients often are admitted when the ER doctor has not heard from the patient’s primary care physician and has no assurance that the practice will assume responsibility for the patient’s well-being. One respondent noted that communication between ER physicians and community physicians has deteriorated in recent years, and that the ER often no longer is interested in avoiding an unnecessary hospitalization.

Physicians noted various practical strategies to assure first contact care after hours. Most agreed that someone from the medical group must be available for patients and for active communication with ERs, as a central tenet of their primary care commitment. Larger practices can hire or contract with nurse triage, providing them access to patients’ electronic health records (EHRs), with a physician back-up for difficult cases. A few interviewed physicians take calls 24/7 from their own patients rather than alternating call with others — giving out their personal cell phone numbers; they have found that patients rarely abuse this privilege, knowing that they would be intruding on the physician’s personal life.

Some practices have established formal relationships with urgent care centers and retail clinics as a preferred alternative to ER care, with established procedures for transfer of clinical information. One practice has worked with local hospitals to achieve a “warm hand-off” from both the ER and inpatient services. This permits the hospital to access the practice’s appointment schedule to make a timely patient appointment, thereby obviating the need for a hospitalization or observation stay.

Addressing Continuity During Hospitalizations

As with after-hours care, respondents generally thought ACO clout could help assure better hospital-ambulatory practice communication and collaboration, while also considering that achieving longitudinal continuity was a core duty of primary care physicians.

Most, but not all, of the respondents had given up inpatient activities over the past decade, with some expressing regret that they would not be there to support their patient during the stress of the inpatient stay and provide useful information to the hospital physicians caring for their patient. They basically felt they could not justify the time away from their practice for a relatively small number of patients.

Yet, a number of the interviewed primary care physicians had developed approaches to assuring their presence was accomplished at times when it would be most useful. As one rural-based physician recounted, “I know it is time to go over there because I learned to put the patient in charge.” That is, the patient calls her before the hospital does with a progress report — and then she is able to participate in her patient’s care by phone even when she can’t get there physically. Some thought that in addition to calling, it would be relatively easy to use Skype-like technology to have visual contact during the inpatient stay.

Another practice requires all of its providers to take “phone call hours” from 8:00 to 9:00 each morning. This allows hospitalized patients and their families to call to discuss the course of the hospital stay and identify issues of concern, and to notify the physician when they need to communicate with the responsible hospital physicians. A few of the interviewees assigned their practices’ care manager to monitor inpatient clinical notes available through an EHR shared with their local hospital, or to simply call hospital staff on a daily basis — and to then alert the patient’s physician when an event occurs that a physician would want to be involved in, such as a new cancer diagnosis. These approaches allow the primary care physician to maintain continuity when it’s most important but do not require the physician to have the lead responsibility for the patient’s hospital care.

Medical Home Versus Good Medicine

When we asked whether the PCMH had ignored the traditional tenets of primary care, one interviewee (a health plan’s medical director) responded, “I don’t know how much of that core primary care is medical home versus good medicine.” That comment captures well our concern about how the PCMH is evolving: while the model calls for substantial redesign of primary care—adopting potentially very beneficial approaches, such as population health, team-based care, and the like—it may not adequately address whether good medicine is being practiced inside the medical home.

Admittedly, first movers and early adopters of the PCMH model likely do practice “good medicine,” and their adoption of the model may very well be producing the positive results observed in some studies, while blazing a trail of what the future of primary care could look like. But our interviews suggest that there are practical ways to foster first contact care and continuity that could be adopted by all practices to strengthen their commitment to these two C’s of primary care, at least (approaches to assuring comprehensiveness seem more elusive). Don’t get us wrong — the PCMH model is a great idea; we just think that to be effective it needs to ensure that the traditional tenets of primary care are included.

1 Trackback for “How Solid Is The Primary Care Foundation Of The Medical Home?”

6 Responses to “How Solid Is The Primary Care Foundation Of The Medical Home?”

I appreciate this information concerning the solidity of the primary care foundation. It is good to learn about the importance of assured after hours access. Something to consider would be to familiarize oneself with the primary care services in local health care clinics to prepare for future concern.

Note my conflicts of interest: I am on NCQA’s 2017 PCMH Committee, and I was in Dr Berenson’s study and am quoted above. More importantly, I am a primary care physician who works without subsidy, or employment or on salary. I simply earn my living by fee for service. Other than patients, I and others like me are the people who need a voice .

There has been no hard fundamental work to transform primary care in my opinion. What there has been is a variety of initiatives designed by non clinicians that have experimented on an already beleaguered field. To transform, practices need breathing room and the proper tools. In primary care we have neither.

To improve access we need to decrease our panel size. We also need either to be paid for all the things people ask us to do or change the regulations that enforce huge volumes of worthless tasks on us, tasks required by others. “But we need this” is the common refrain, and it is not coming from patients.

Comprehensive care has also to do with empanelment, but there are more and more things that are available to patients and this is also one reason referrals have gone up. There is just more to do.

Care coordination means simply that we tracked the referral and took action on it. But PCPs have become the go-to for everything no one else will or can do and are expected to be file cabinets, librarians, and administrative assistants for all of medicine, as we scan and file the echocardiogram done outside of our own system and keep a dozen passwords for access — which will only be reset by a real person who went home at 4. THESE are things we need. We buy ppd testing materials in vials of ten, get paid for one and waste nine (no good after 30 days did ya know?), and then complain when it’s back ordered. We are forced to buy vaccines in 10 dose quantities when we need one.

I can go on. We need to stop being asked to sign off on the PT plan of care so PT can be paid, when it is really fraud to ask us to assess this. We need to stop changing formulary meds every January while doctors frantically read about the newly covered option which is something we have no skill in using.

The solutions are policy related and political and have little to with “PCMH.” We should expect that PCPs provide those four Cs and design their practices to do so. But for many, the barriers to making any change are overwhelming. We cannot transform practices that cannot breathe and we cannot breathe until we are unburdened. I can write for an hour about the ridiculousness of our days. Yesterday a payer would not cover amitriptyline for $13.00 The day before I had to change ranitidine tabs to ranitidine caps for coverage. Can you spell waste?

We need fundamental radical change in policies, cooperation from specialists to change their behavior, and we need to be on one EMR; it’s a shame so many millions of dollars in meaningful use money was wasted — that should’ve been gotten over with and the pain long since done with.

NCQA is full of well-meaning people — really, these are delightful people — but you’ll never have doctors who take a NCQA PCMH program to heart; they will always be accountable to their patients and to themselves. There’s probably no hope for primary care in this country though Dr Berenson and Ms Burton are voices crying in a wilderness and have it right

Barr and Berenson are at odds because Michael defends his well-intentioned programs, but we have done what Berwick says is full employment for vendors while Berenson sees a bigger picture. NCQA is a vendor. They are not publicly accountable.

Unfortunately when I paint the blunt picture I get feedback that I am blunt/ whining/ or too direct. When ortho gets 3 times what I do for a 99213, they are expert negotiators who are valuable.

PCMH is indeed jargon for good primary care. Trying to provide good primary care, we find ourselves shackled without courageous leadership and fundamental change.

We must rid primary care of coding and billing, watching as some payers pay the 25 modifier with a preventive visit and others refuse, etc. There was applause when Medicare initiated chronic care codes but at any given time only a few patients need these, and if you perform 20 minutes of service but later in the month, on the day you happen to bill, the patient is in the hospital, Medicare will tell you to return the money because they can’t comprehend that the patient received services earlier; they will reprimand you that she can’t have been in the hospital and in your office at the same time, and, therefore she was not eligible for services.

We’re manacled by the increasing bureaucracy of the VFC program. In a country that has had success in eliminating vaccine preventable disease, there simply is no evidence that we need tighter controls on the recording of refrigerator temperatures; staggering layers of time-sucking and mind-numbing chores keep us from the real work.

I note that only 44% of family practice residency slots were are filled by U.S. seniors this year. I thank Dr. Berenson and his coauthor for several recent articles and for their work. I think they are a voice crying in the wilderness.

I identify myself as the person who talks to her patients by phone, when they are in the hospital, as mentioned above. I’m on call 24/7, have superb cost and quality metrics, and am counting the days til I can stop working. There is no certification that is worth the paper it is on if we do not make deep fundamental changes to the workday of the PCP

The authors have CORRECTLY identified a major problem with the NCQA version of PCMH-it doesn’t work!

NCQA is-still- the biggest piece of the problem, not a solution. “Many of the versions of the PCMH—and the accompanying recognition instruments (e.g., NCQA!) that assess practice adoption of the PCMH model—do not assure that the well-established four “pillars” of primary care are robustly adopted…”
and in fact the NCQA hoops increase documentation burden, which is the #1 cause of PCP burnout. They’re measuring the wrong things, the wrong way.

The biggest problem with building a REAL PCMH is it costs more, and the increased work mandated by MU,MIPS,NCQA, etc. cost more than the PCMH payments. The original PCMH papers included a necessary element- payment reform- that recognizes the critical importance of primary care to an efficient, effective healthcare system, but it’s been left out of reform schemes. As Bazemore noted, in the US, primary care gets 5% of the money, while in functional systems, it’s 10-12%. As one doctor said, “I’m tired of doing more for less. I’m going to do less for less.” That’s the crux of the problem. Ash described how risk-adjusted payment for all the extra services we need for enhanced primary care can improve outcomes.

To fix the health care system, we need to fix primary care. Primary care has two sucking chest wounds that must be addressed first-
1 the dirty secret that payment has gotten way out of proportion to value, and primary care is underfunded. Paying insurance company flacks to take over primary care roles won’t work. (“I’m from the insurance company, and I want to help improve your health,” isn’t going to hack it.) Ash & Ellis’s model, or Gorrell’s is probably the best. FWIW, in MS groups, it costs $100,000/yr/MD in 2015 dollars to ‘deal’ w. insurance companies. Probably $180k in primary care w more charges, lower tickets. FFS bad, risk-adjusted capitation good.
2 We need an easy, useful quality measure that EVERYONE accepts, just like PCMH is the universal solution for MACRA.

Three quarters of PCPs say current ‘quality’ measures are either useless or actually harmful in the pursuit of better care. A recent HA article documented 20,000+ different ‘quality’ measures in use, and they’re the #1 cause of burnout. To get out of a hole, the first thing to do is to stop digging!!

We have a validated, patient-centered quality measure that gives actionable data without substantial PCP work, and it correlates closely to CAHPS. It’s Dr Wasson’s HowsYourHealth.org. If CMS simply said, “yes, you can use HYH to measure quality and everyone else has to accept it too,” it would save ~$18 billion/year. And lots of PCP hair not pulled out.

Adding risk-adjusted primary care-only-capitation at 11% of premium plus HYH to measure quality would go a long way toward rebuilding primary care.

Excellent and thought provoking. Have we taken our eye off the ball of educating clinicians to deliver excellent person-centered care? Yes! Coordinating inapprppriate care will not succeed. We need to refocus on adequate training of the future workforce and retraining of the existing one.

Berenson and Burton take a decidedly negative perspective on the tremendous amount of work going on around the United States to transform primary care practices into high-performing, well-organized, person-centered hubs of health care delivery. Lost in the critique are some facts about the NCQA recognition criteria and how they have evolved in response to the issues identified.

It is important to provide a bit of context. In March 2007, the Joint Principles of the Patient-Centered Medical Home were released by ACP, AAFP, AOA, and AAP. Large employers and insurance companies embraced the concept but asked for a process to identify practices demonstrating the attributes of the PCMH. This led to the first version of the NCQA PCMH Recognition program in 2008. Since then, NCQA has updated the standards in 2011 and 2014. There are currently over 56,000 clinicians (approximately 17% of primary care physicians) practicing in over 12,000 NCQA-recognized practice sites in the United States. We are currently in the process of reviewing/updating the NCQA standards for release in March 2017 with an entirely redesigned process for practices interested in seeking or sustaining recognition [Detailed information at http://blog.ncqa.org/recognition-redesign-google-hangout-video/; http://blog.ncqa.org/recognition-redesign-questions/; http://blog.ncqa.org/does-pcmh-work/%5D. For each update, NCQA combs the literature, speaks to key stakeholders, invites public comments, analyzes data about practices that have achieved recognition, and convenes an advisory group representative of practices, employers, consumers, payers, and state/federal agencies.

The 2014 NCQA PCMH standards address many of the issues identified by Berenson and Burton. With respect to first contact, PCMH Standard 1 focuses exclusively on access to care. Element 1 includes a critical factor requiring practices to provide same day appointments for routine and urgent care. A critical factor must be met in order for the practice to achieve any points for that element. Element 1 also sets the expectation for routine and urgent care appointments outside regular office hours and element 2 include another critical factor requiring practices to provide timely clinical advice by phone. A related expectation is that the medical record is available for care and advice even if the office is closed.

Regarding continuity, PCMH Standard 2 includes expectations that people are assigned a personal clinician and that the practice monitors the percentage of visits with that clinician or team. There are robust expectations for communicating how the medical home coordinates care, provides after hours care, demonstrates equal access to all patients regardless of payment source – all of which support continuity. Further, Standard 2 specifically references the expectation that to be an effective medical home, the practice should have comprehensive patient information about visits to specialists and data from recent hospitalizations, specialty care and emergency department visits.

Comprehensiveness is clearly important but a significant challenge to measure as documented by O’Malley and Rich [O’Malley, A and Rich, E., 2015, Measuring Comprehensiveness of Primary Care: Challenges and Opportunities, Journal of General Internal Medicine, vol. 30]. We acknowledge that there is more work to do. NCQA invited Dr. O’Malley to join the NCQA PCMH 2017 advisory committee and that group is considering ways to improve how the program can assess comprehensiveness. Nevertheless, we should not ignore the major expectations for primary care practices included in the PCMH 2014 standard that contribute to comprehensiveness: comprehensive health assessments, care coordination, care management, population health, shared-decision making, use of clinical decision support, patient engagement, patient experience surveys, and continuous quality improvement.

NCQA strives to achieve a balance between setting expectations yet not getting too prescriptive about how practices implement PCMH attributes. As a result, PCMH’s vary in their characteristics and their progress towards the ideal – something that is hard to account for in evaluating the model. The research to date suggests that given enough time to anchor new changes into the culture of a practice, and with ongoing financial and technical support, PCMHs do trend towards improving key aspects of quality, utilization and patient experience. Berenson and Burton take particular aim at primary care but I am sure they would acknowledge that it will require more than the PCMH program to address the silos in health care. Even if all of primary care were to practice at the highest level of medical homeness, unless there is alignment along the same principles among specialists, hospitalists, work site and retail clinics, and everywhere else that people receive care, we will continue to look at the output of our health care delivery system and want better.

March 28th, 2016 at 7:09 pm

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